By Patricia Prewitt 

My Personal Rx Advisor 

Often, sticker shock arises when a new medication is prescribed. It’s frustrating to have no idea what the cost may be. It can be even more surprising when a routine medication is no longer covered, or jumps dramatically in price.

What are steps to take when coverage seems to have changed?

First, make sure that your prescription plan information is correct. Computer updates may default to old information. Most of these errors tend to occur from one calendar year to the next. Mid-year glitches happen when plans update coverage on July 1.

For example, if you have a common name, or share a birthday with someone of the same name, computer files can more easily get transposed.

Second, think back – did you receive a notice in the mail that coverage was changing? For Medicare Part D enrollees, if your plan is making a negative formulary change such as removing a drug, moving it to a higher tier, or adding prior authorization, they must notify affected members at least 30 days before the change takes effect. (Reg 42 C.F.R 423.120)

What can I do? Plan members are allowed to request a one-month supply of the medication under the old rules. This allows time for contacting the prescriber to see if a covered or less costly alternative is available.

Is there anything my prescriber could do to help? If insurance denies coverage, services such as CoverMyMeds can help push an approval. This may take 5-10 business days depending on the complexity of the clinical data.

What is the benefit of having my medications approved by the insurance plan?  For Medicare Part D enrollees, once you have met your annual deductible and out-of-pocket costs reach $2,100  the plan will cover remaining costs until the end of 2026. Costs for approvedmedications accrue towards meeting those deductibles.

I recently worked with a Medicare client to help her understand that despite her high initial costs for approved use of a GLP1, she was financially better off using her plan. Direct pay cash of $299 per month x12 months=$3,588, vs $2,100 out of pocket capped.

Can I ask in advance if a medication is covered by my plan? Yes, this would be a good tactic. There are several professional apps, such as Coverage Search and Fingertip Drug Coverage, that help clinicians identify formulary status. However, they will not show an exact price.

What if I decide to pay cash for the prescription-not use my insurance plan?

Sometimes, this can be a smart choice. Savings cards like GoodRx, SingleCare, and TrumpRx offer lower cash prices on some  medications than traditional insurance plans. Mark Cuban’s CostPlusDrugs and Amazon pharmacy offer low cost generics via mail.

Direct-to-consumer programs for prescriptions from pharmaceutical manufacturers are becoming more prevalent. These programs operate outside of the traditional insurance plan model and costs will likely not accrue toward any insurance deductible.

Those who routinely itemize medical expenses for a tax deduction would need to seek the advice from a CPA/tax advisor as to how these cash pay expenses are treated, as laws vary by state.

Content provided is for educational purposes only and is not intended as a substitute for advice from a qualified medical professional. The opinions expressed within are those of the author. 

About the Author: Patricia Prewitt is a local Massachusetts resident who spent more than 30 years in the pharmaceutical industry. Tricia is a consumer education advocate, and loves helping people find ways to save money on their prescriptions. More information and free resources are available on her website at https://mypersonalrxadvisor.com/resources or call her at 508-507-8840. Favorite Quote: ”Act as if what you do makes a difference. It does.” – William James